• No results found

In-service training to improve phlebotomy technique

N/A
N/A
Protected

Academic year: 2021

Share "In-service training to improve phlebotomy technique"

Copied!
97
0
0

Loading.... (view fulltext now)

Full text

(1)

Title&Page:

!

! ! ! ! ! ! !

In$service!training!to!improve!phlebotomy!

technique!

!

By!

!

Lizelle!Crous!

!

!

!

!

!

!

!

!

!

A!research!report!submitted!for!fulfillment!of!the!partial!

requirements!for!a!degree!of!Masters!in!Nursing!at!the!Faculty!of!

Health!Sciences,!School!of!Therapeutic!Sciences!at!the!University!of!

the!Witwatersrand.!

(2)

Declaration:!

! !

!

I,!Lizelle!Crous,!declare!the!following:!

!

This!research!report!being!submitted!for!the!partial!requirements!of!the!

degree;!Master!of!Science!(MSc)!Nursing,!at!the!University!of!the!

Witwatersrand,!Johannesburg!is!my!own!work!and!has!not!been!submitted!

before!for!any!degree!at!any!other!institution.!

!

!

!

Signature:

!!______________!

!!!!!!!!!!!!!!!!!!!!!!!!Lizelle!Crous!

!

!

Signed!at!Randburg,!on!the

!!!

13th

!!!

day!of

!!!!

February!2015

!

!

!

!

!

!

!

!

Protocol!number:!!M130466!

!

!

(3)

Dedication:

!

! ! ! This!research!report!is!dedicated!to!all!the!Nurses!working!in!the!laboratory.!!! ! “You%can%achieve%an%ordinary%level%of%success%by%targeting%objectives%that%are%accessible%to% you.%%Or%you%can%chase%a%more%elusive%target%and%shoot%for%the%stars!”%% Nigel!H.!Martin! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !
(4)

Acknowledgements:

!

! So!many!people!have!inspired!me,!contributed!to!and!influenced!me!whilst!conducting!and! writing!up!this!research!report.!!I!came!to!the!realization!that!no!woman!is!alone!in!any! venture.!!! Knowledge!is!power!but!doesn’t!come!without!pain!and!effort!and!many!a!day!I!thought!of! giving!up,!but!then!new!inspiration!reveals!itself!and!you!find!reasons!to!continue.!!! I!want!to!thank!Dr!Sue!Armstrong,!my!supervisor,!for!keeping!me!on!track!and!motivating! me!to!continue,!always!reminding!me!of!the!finishing!line!that!is!around!the!corner.! To!my!husband,!Albert!Crous,!thank!you!for!believing!in!me,!challenging!me!to!become!the! person!I!am!today.!!Without!your!support!and!constant!reminder!to!believe!in!myself,!this! would!not!have!been!possible.!!I!am!honoured!to!live!and!work!alongside!you!everyday.!!! To!my!daughter,!Elize,!and!stepdaughter,!Liezle,!thank!you!for!stepping!up!and!keeping!the! house!in!order!while!I!was!in!another!“literary”!world.! Special!thanks!to!Johanette!Bezuidenhout!and!her!team,!for!encouraging!me!till!the!end!and! helping!me!with!this!project.! Last!but!not!least,!all!the!staff!of!the!Nursing!Education!Department!of!Wits,!thank!you!for! supporting!me,!your!advice!and!input!was!appreciated.! ! ! ! !
(5)

Abstract:!

! Competence!of!nursing!staff!working!in!the!laboratory!came!under!the!spotlight!with!the! introduction!of!the!phlebotomist!technician$learning!programme.!!In!modern!medicine! doctors!rely!on!clinical!laboratory!services!to!assist!them!with!managing!patient!care.!!They! use!information!from!the!laboratory!to!diagnose!and!treat!patients!and!it!is!therefore!of!the! utmost!importance!to!ensure!quality!specimens!are!produced!enabling!accurate!test!results.! ! Phlebotomy!is!considered!a!skill!and!not!a!discipline!and!needs!workplace!training! programmes!and!policies!to!prevent!errors.!!Sample!collection!takes!place!in!the!first!phase! of!the!testing!process,!pre$analytical,!and!is!mainly!performed!by!nursing!staff,!and!when! looking!at!error!statistics,!60!–!70%!of!recorded!errors!are!taking!place!in!the!pre$analytical! phase,!causing!negative!outcomes!for!the!patient!and!involves!risks!that!ranges!from!no! harm!detected!to!death.! Despite!in$service!training,!problems!were!identified!that!is!related!to!the!phlebotomist’s! technique!when!performing!a!venepuncture.!!Therefore,!establishing!if!nurses’!phlebotomy! technique!can!be!improved!through!a!training!programme!would!provide!valuable! information!in!the!attempt!to!improve!quality!results.! ! The!purpose!of!this!study!was!to!identify!technique!variations!of!nursing!staff!and!develop!a! training!programme!directed!to!correct!phlebotomy!technique!variations!and!finally!to!test! the!effectiveness!of!such!training!programme.!
(6)

The!methodology!used!was!a!quantitative,!experimental,!pilot!intervention!study!to!provide! guidance!in!answering!the!research!questions!based!on!a!one!group!pre$test!post$test! design.!!Data!was!collected!by!means!of!peer!video!recordings!of!the!nurses!employed!by! the!laboratory!(n=20)!in!the!workplace,!based!at!outpatient!departments!of!the!laboratory,! which!was!then!evaluated!by!independent!evaluators!against!a!criterion!based! observational!checklist.!!! ! Compliance!to!standards!on!the!venepuncture!procedure!was!identified!during!the!pre$test! with!an!average!score!of!61.9%.!!The!training!programme!developed!to!address!all! deviations!from!the!standards!proved!to!be!effective!as!the!post$test!mean!score!was!85%.!! The!results!suggests!that!knowledge!and!skills!were!acquired!however!further!investigations! are!needed!for!guidance!in!standardisation!of!training!programmes!and!the!interval! programmes!should!be!presented.!!! ! ! ! ! ! ! ! ! ! !

(7)

!

Table&of&Contents:

!

! Declaration! ii! Dedication! iii! Acknowledgements! iv! Abstract! v! Table!of!Contents! vii! List!of!Figures! ! x! List!of!Tables! ! xi! ! ! Chapter(1:((Overview(of(the(Study( 1.1!Introduction! ! 1! 1.2!Background! ! 2! 1.3!Definitions!and!explanatory!notes! ! 6! 1.4!Problem!statement! ! 8! 1.5!Purpose!of!the!study! ! 8! 1.6!Research!questions! ! 9! 1.7!Research!objectives! ! 9! 1.8!Significance!of!the!study! ! 9! 1.9!Overview!of!methodology! ! 10!
(8)

! Chapter(2:((Literature(Review( 2.1!Introduction! ! 12! 2.2!Nurses!vs.!Phlebotomists! ! 14! 2.3!In$service!training! ! 15! 2.4!Venepuncture:!!procedural!errors!and!associated!complications! ! 19! 2.5!Quality!assurance:!Current!status!in!South!Africa! ! 21! ! Chapter(3:((Research(Methodology( 3.1!Introduction! ! 23! 3.2!Research!methodology! ! 23! 3.3!Research!design! ! 25! 3.4!Overview!of!research!plan! ! 26! 3.5!Research!setting! ! 28! 3.6!Population!and!sample! ! 28! 3.7!Research!method! ! 29! 3.7.1!Phase!1:!!Validating!instrument! ! 30! 3.7.2!Phase!2:!!Data!collection! ! 32! 3.7.2.1!Pre$test! ! 33! 3.7.2.2!Intervention! ! 34! 3.7.2.3!Post$test! ! 35! 3.7.3!Phase!3:!Additional!information! ! 35! 3.8!Data!analysis! ! 36!

(9)

3.9!Validity!and!reliability!of!study! ! 37! 3.10!Ethical!considerations! ! 38! Chapter(4:((Findings( ( ( 4.1!Introduction! ! 41! 4.2!Pre$test!results! ! 41! 4.3!Post$test!results! ! 46! 4.4!Additional!information!from!laboratory! ! 48! 4.5!Demographic!data! ! 50! 4.6!Discussion!of!results! ! 52! ! ! Chapter(5:((Conclusions,(Limitations(and(Recommendations( 5.1!Introduction! ! 59! 5.2!Summary! ! 59! 5.3!Main!findings! ! 60! 5.4!Limitations! ! 61! 5.5!Recommendations!for!nursing!education! ! 62! 5.6!Recommendations!for!nursing!research! ! 62! 5.7!Recommendations!for!nursing!practice! ! 63! 5.8!Conclusion! ! 64! ! ! References! ! 65!

(10)

List%of%Figures:

!

! ( Chapter(3( 3.1!Summary!of!Research!Plan! 27! ( Chapter(4( 4.1!Top!Performers! 42! 4.2!Middle!Performers! 43! 4.3!Low!Performers! 45! 4.5!Participant!Pre$Test!Performance! 46! 4.6!Participant!Post$Test!Performance! 47! ! 4.4!Pre$Test!/!Post$Test!Comparison:!Steps!1$18! 48! 4.5!Sample!Rejection!Numbers! 49! 4.6!Demographic!Questionnaire:!Question!1! 50! 4.7!Demographic!Questionnaire:!Question!2! 50! 4.8!Demographic!Questionnaire:!Question3! 51! 4.9!Demographic!Questionnaire:!Question!4! 51! 4.10!Demographic!Questionnaire:!Question!5! 52! ! ! !

!

(11)

!

List%of%Tables:!

! ( Chapter(3( 3.1!Changes!to!Checklist! 31! ( Chapter(4( 4.1!Participant!Feedback! 55!

!

!

!

! ! ! ! ! ! !
(12)

Appendices:

!

!

!

Annexure!A.1! Checklist!used!in!Pre$!and!Post$test! xiii!

Annexure!A.2! Ampath!laboratory!checklist! xiv!

Annexure!A.3! Checklist!used!in!trial!run! xix!

!

Annexure!B! Demographic!Questionnaire! xx!

!

Annexure!C.1!! Nurse!Participant!information!letter!and!consent!form! xxi! Annexure!C.2! Patient!information!letter!and!consent!form! xxiii! !

Annexure!D.1! Permission!letter!to!CEO!of!private!laboratory!and!the! !

! Response!from!CEO! xxv!

Annexure!D.2! HREC!ethical!clearance!certificate! xxvii! ! !

Annexure!E! Training!programme! xxviii!

! ! ! ! ! ! ! !!!!

(13)

Chapter(1:(

Overview(of(the(Study(

!

1.1

Introduction(

This%chapter%encapsulates%the%research%process%and%gives%a%brief%overview%of%the%study.%% With%the%introduction%of%the%phlebotomist%technician:learning%programme,%the%competence% of%nurses%performing%this%role%came%under%the%spotlight%with%regard%to%their%level%of%skill% when%performing%a%venepuncture%as%they%had%never%previously%been%specifically%trained%for% or%evaluated%when%performing%this%skill.%Nurses%were%assumed%to%be%able%to%perform%this% function%but%in%reality%their%training%on%venepunctures%is%very%limited%when%measured% against%the%18%month%focused%training%of%a%phlebotomist%technician.%%% Nurses%have%for%many%years%been%required%to%perform%venepunctures%in%hospital%wards%and% outpatient%departments%to%assist%doctors%with%their%workload.%%It%was%therefore%not%a%strange% phenomenon%for%nurses%to%be%employed%as%phlebotomists%in%the%laboratory%to%assist%pathologists% with%the%demand%of%sample%collection,%as%doctors%began%to%rely%more%on%diagnostic%tests%to%make% a%diagnosis.%%The%shortage%of%professional%nurses%and%the%increase%in%the%number%of%patients% making%use%of%the%private%health%care%system%resulted%in%a%need%and%demand%for%more%skilled% phlebotomy%staff.%%This%led%to%the%development%of%the%phlebotomist%learning%programmes,%and% the%consequent%realization%that%nurses%did%not%necessarily%meet%the%requirements%for%correct% venepuncture%technique.%
(14)

%

1.2

Background(

In%modern%medicine,%doctors%rely%on%laboratory%services%to%assist%them%with%patient%care% management.%They%use%the%information%obtained%from%the%laboratory%to%diagnose,%or%exclude%a% diagnosis,%and%to%treat%patients.%It%is%therefore%important%that%the%laboratory%produces%quality% test%results.%%Sample%collection%is%done%manually%and%human%errors%are%therefore%inevitable.%To% avoid%mistakes,%care%should%be%taken%to%ensure%that%competent%personnel%follow%the%correct% processes.%%(Wonglumsom,%Manochiopinij,%Sirisali,%Vattanaviboon%and%Sirisali,%2011).%% Phlebotomy%is%considered%an%acquired%skill%and%not%a%discipline;%therefore%effective%policies%and% workplace%training%are%needed%to%facilitate%the%prevention%of%errors.%%%Laboratory%work%is%divided% into%3%phases%–%pre:analytical,%analytical%and%post:analytical.%%Nurses%are%mainly%involved%in%the% pre:analytical%phase%and,%when%looking%at%the%statistics,%60%–%70%%of%errors%occur%in%the%pre:% analytical%phase.%%(Sharma,%2009).%%Pre:analytical%procedures%include%tasks%from%the%time%of% receiving%the%patient%to%the%time%the%specimen%is%received%in%the%laboratory.%%% An%opportunity%for%errors%is%created%when%nurses%lack%knowledge%about%laboratory%practices%or% do%not%have%the%appropriate%skill%to%perform%the%necessary%procedures.%%Lack%of%quality%control% might%also%be%an%issue.%%Phlebotomy%is%a%neglected%procedure%in%healthcare.%Limited%time%is%spent% on%training%nurses%and%doctors%on%the%procedures%and%yet%it%involves%serious%health%risks,%which% could%result%from%improper%venepuncture%technique%impacting%on%the%patient%treatment% outcomes.%%Two%of%the%major%complications%that%can%occur%due%to%improper%technique%are% haemolysis%and%haemoconcentration.%%%Prolonged%tourniquet%application%will%result%in% haemoconcentration,%where%blood%plasma%infiltrates%the%surrounding%tissue%causing%an%increased%
(15)

concentration%of%protein:based%analytes%in%the%blood.%%A%haemolysed%sample%is%unacceptable%for% testing%and%will%result%in%the%patient%being%re:bled.%%The%following%technique%errors%will%ultimately% result%in%a%haemolysed%sample:%%Needle%size%smaller%than%23:gauge;%drawing%from%a%bruised%area% or%haematoma;%applying%the%tourniquet%too%close%to%the%puncture%site;%inserting%the%needle% before%the%cleaning%agent%has%air:dried%and%mixing%the%tubes%vigorously.%(Strasinger%and%Di% Lorenzo,%2011).% Ernst%(2006)%stated%that%when%patients%come%for%a%blood%test,%they%demand%“the%knowledge%and% skills%of%a%competent%phlebotomist”.%%The%nurse%(phlebotomist)%is%the%responsible%person%to% ensure%specimen%quality%in%the%pre:analytical%phase%of%laboratory%tests.%%Errors%in%the%pre:% analytical%phase,%especially%during%the%specimen:collection%process,%causes%negative%outcomes%for% the%patient%that%ranges%from%no%harm%detected%to%death.% Research%indicates%that%phlebotomy%training,%although%it%is%in:service%training,%must%be%of%good% quality%so%that%the%phlebotomist%understands%the%implications%of%wrong%technique%and%errors%in% the%pre:analytical%phase’s%impact%on%test%result%outcomes.%%(Ernst,%2011).%%%% Good%venepuncture%technique%secures%a%satisfactory%specimen%and%minimises%patient%discomfort.%% In%this%study%the%venepuncture%procedure%will%be%standardised%to%eliminate%variations%in% technique%together%with%implementing%control%measures%to%improve%the%quality%of%the%collection% method%(venepuncture).%%Lack%of%control%eventually%results%in%improper%technique%or%bad%habits.% Previous%studies%(Hawkins,%2012;%%Green,%2008;%%Sharma,%2009;%%and%Lippi,%2009)%investigated%the% errors%that%can%occur%if%the%wrong%technique%has%been%followed,%and%indicate%it%is%vital%to%improve% the%quality%of%service%being%rendered.%%%Although%all%studies%indicate%that%training%is%vital%there%is%

(16)

Salvagno,%Montagnana,%Franchini%and%Guidi,%2006).%%There%is%an%assumption%that%nurses%are%able% to%perform%a%venepuncture%correctly%as%it%is%one%of%the%skills%demonstrated%during%the%course%of% the%programme%to%qualify%as%a%nurse.%%Unfortunately%nursing%students%have%limited%opportunities% to%practice%and%perfect%this%skill%as%most%laboratories%(public%and%private)%have%trained%nursing% staff%in%their%employment%to%obtain%samples%for%testing%and%do%not%accept%student%nurses%for% practical%placements.%%Due%to%the%limited%opportunities%nurses%have%to%obtain%phlebotomy%skills,% the%focus%of%the%nurse%shifts%from%the%venepuncture%technique%to%accessing%a%vein%for%intravenous% therapy.%%Even%if%the%nurse%has%many%years%of%experience%in%starting%an%IV,%a%different%approach%is% involved%to%perform%a%successful%venepuncture.%%(Ernst,%1998).% In%the%earlier%years,%nurses%had%many%opportunities%to%become%competent%in%different%skills%such% as%venepuncture%and%starting%an%IV,%as%they%would%work%alongside%the%doctors%who%did%not%mind% delegating%certain%tasks%once%demonstrated%to%nurses.%%Decentralizing%laboratory%services%has% meant%that%phlebotomy%procedures%previously%performed%by%ward%staff%are%now%performed%by% nurses%and%technicians%employed%by%the%laboratory%thus%limiting%opportunities%for%developing% expertise%in%the%skills%while%working%in%the%hospital.%%Capacity%issues%in%the%hospital%setting%also%led% to%nurses%passing%the%role%of%collecting%specimens%to%the%laboratory%staff,%resulting%in%nurses% losing%the%ability%to%perform%this%skill.%%Student%nurses%seldom%get%an%opportunity%to%become% competent%in%phlebotomy%procedures%during%their%years%of%study,%and%might%only%manage%the% skill%once%qualified%as%a%professional%nurse.% The%literature%does%not%answer%the%question%on%the%effectiveness%of%training%and%whether%training% ensures%competent%and%skilled%staff.%%In%a%special%report%by%Ho,%Purdy,%Adrian,%Higa%and% Cembrowski%(2002)%they%observed%trained%phlebotomists%with%years’%experience%on%their%

(17)

phlebotomists%were%noncompliant%in%13%of%them.%%Based%on%the%results%of%this%study,%the% effectiveness%of%the%training%programme%and%the%methods%of%training%are%questionable.%% Dennis%Ernst%(1998)%describes%the%four%indefensible%phlebotomy%errors,%one%of%which%is% insufficient%training.%The%medical%communities%assume%that%nurses%have%the%skill%and%knowledge% to%perform%venepunctures.%%A%venepuncture%procedure%is%very%different%to%starting%an% intravenous%infusion.%Ernst%(1998)%wrote:%“What%may%appear%to%be%a%simple,%quick%procedure% involves%a%good%deal%of%knowledge%and%technique%to%perform%correctly”.%%It%is%no%use%having%a% well:designed%programme%if%the%evaluation%process%is%lacking.%%This%will%defeat%the%purpose.%%Ernst% (2006)%states%that%evaluation%should%take%place%on%a%regular%basis%for%3%:%6%months%in%the% beginning%and%repeated%biannually.%%This%is%to%ensure%competence%is%current,%procedures%updated% and%the%margin%for%error%minimised.% In%the%private%sector%nurses%are%employed%as%phlebotomists%and%are%responsible%for%the%%%% collection%of%specimens.%%They%receive%in:service%orientation%on%company%procedural%standards% and%have%to%complete%a%knowledge%assessment.%%The%nurses%are%only%observed%and%assessed%once% they%are%in%the%workplace%to%see%if%they%acquired%the%skills%to%perform%a%venepuncture.%%The% question%arises%that%if%the%training%programme%is%effective%and%the%operating%procedures%are%in% place,%why%was%there%an%increase%in%documented%pre:analytical%errors%at%the%private%laboratory% between%July%2011%till%July%2012?%(Management%Review%Report:%%Ampath%Laboratories%2012).%%The% problems%that%were%identified%related%to%wrong%technique%were:%%patients%complaining%about% having%bruises%or%haematomas%after%a%venepuncture%procedure%was%performed%and%samples%that% have%to%be%re:drawn%due%to%haemolysis%or%under%filled%specimen%containers.%%Micro%clots%in%the% blood%sample%also%affect%the%results%and%render%the%sample%unsuitable%for%testing.%This%is%caused%

(18)

even%when%the%container%was%not%inverted%adequately%after%collection%or%a%combination%thereof.%% (Ampath%Quality%Report%2012).% The%only%way%to%improve%the%quality%of%the%specimens%and%to%reduce%errors%whilst%performing%the% procedures%is%to%observe%staff%while%they%perform%a%venepuncture%and%identify%the%mistakes%they% make.%%Even%more%importantly%to%test%their%understanding%of%the%impact%of%that%particular%error% has%on%the%outcome%of%the%test.%%(Ernst,%2011).%%Norcini%and%Burch%(2007)%suggest%that%providing% feedback%on%performance%after%an%observation%in%the%workplace%will%add%value%to%the%learning% process%and%improve%the%quality%of%care%rendered.%%% %

1.3

Definitions(and(explanatory(notes(

• Adult:%%Person%18%years%of%age%and%older%and%able%to%sign%consent%for%a%procedure,%and% capable%by%law%to%do%so.% • Ante%Cubital%fossa%area:%%Acceptable%location%for%blood%collection%because%3%prominent% veins%are%located%in%this%area%–%Median%Cubital%(1st%choice),%Cephalic%(2nd%choice)%and%%% Basilic%(3rd%choice).% • Laboratory:%%Refers%to%a%private%clinical%pathology%practice%performing%tests%on% specimens%collected%by%nursing%staff.%% • Phlebotomy:%%Method%used%to%access%a%vein%or%artery%to%obtain%a%blood%sample.%% • Phlebotomist:%%%A%qualified%person,%a%registered%nurse%or%a%phlebotomy%technician,% working%for%the%laboratory%collecting%samples%for%testing.%%The%laboratory%also%employs% enrolled%nurses%as%phlebotomists,%however%they%work%under%the%direct%or%indirect% supervision%of%a%registered%nurse.%%%
(19)

• Pre:analytical%errors:%%Occurs%if%the%steps%in%the%venepuncture%procedure%are%not%%%%%%%%% performed%correctly.%%For%the%purpose%of%this%study%errors%might%include:%(the%possible% affect%is%given%in%brackets).% ! Recontamination%of%collection%site%(possible%source%of%infection)% ! Cleaning%agent%not%allowed%to%air%dry%(haemolysis)% ! Tourniquet%applied%to%close%to%collection%site%(haemoconcentration)% ! Tourniquet%not%loosened%within%1%minute%(haemolysis)% ! Vein%selection%–%Median%Cubital%not%first%choice%(not%palpating%for%most%appropriate% vein)%(may%result%in%re:bleeding%the%patient)% ! Vein%not%stabilized%correctly%(bruising%or%haematoma)% ! Needle%size%too%big%or%small%for%vein%selected%(haemolysis)% ! Needle%insertion%angle%greater%than%20˚%(haemolysis%due%to%haematoma%formation)% ! Specimen%containers%(tubes)%not%filled%in%the%correct%order%(reflux%of%preservative%–% contaminated%specimen%–%unsuitable%for%testing)% ! Blood%not%mixed%properly%by%inverting%the%tube%3:4%times%after%filling%with%blood.%% (Haemolysis).%%(Green,%2008).% • STAT%lab:%%This%is%a%small%branch%of%a%laboratory%based%at%hospitals%with%an%emergency% department%and%critical%care%units.%%A%STAT%lab%only%performs%life:threatening%tests%and% will%provide%results%within%an%hour%after%collection.%%The%turnaround%time%for%test%results%

(20)

for%specimens%sent%to%a%reference%laboratory%will%range%between%3%–%6%hours%depending% on%the%distance%travelled.% • Technique:%%To%what%extent%does%the%nurse%avoid%making%conscious%errors%during%the% venepuncture%procedure.% %

1.4

Problem(statement(

Despite%in:service%training%the%laboratory%identified%numerous%problems%related%to% phlebotomists’%technique.% The%orientation%programme%that%new%employees%attend%is%aimed%at%getting%nursing%staff% ready%and%competent%to%perform%venepunctures%as%soon%as%possible%and%the%duration%of%the% programme%is%7%days.%%%Ernst%(2006)%states%that%evaluation%of%competence%should%take%place% on%a%regular%basis%however%in%reality%once%the%nurse%starts%his/her%phlebotomist’%working% career,%no%evaluation%takes%place.% Therefore,%an%attempt%to%establish%if%nurses’%technique%can%improve%through%a%standardized% in:service%training%programme%should%be%made.% %

1.5

Purpose(of(the(study(

To%develop%an%in:service%programme%directed%to%correct%phlebotomy%technique%errors.% To%evaluate%the%effectiveness%of%the%in%service%training%programme,%i.e.%that%quality%is%improved% by%eliminating%procedural%variations.% %
(21)

1.6

Research(questions(

• What%is%the%current%level%of%compliance%to%the%standard%operating%procedures?% • What%elements%should%be%included%in%a%training%programme?% • Does%the%programme%make%a%difference%in%the%quality%of%the%nurse’s%phlebotomy%%%%% technique?% %

1.7

Research(objectives(

• To%determine%the%level%of%compliance%of%the%nursing%staff%to%the%standard%operating% procedures%of%the%laboratory.% • To%develop%a%training%programme%to%correct%specific%technique%problems.% • To%test%the%effectiveness%of%such%training%programme.% %

1.8

Significance(of(the(study(

Diagnostic%testing%and%“drawing%blood”%form%part%of%the%skills%required%of%a%person%to% practice%as%a%professional%nurse%in%South%Africa.%%Unfortunately,%there%is%no%clear%guidance% concerning%time%spent%and%level%of%competence%required%to%perform%phlebotomy% procedures.%%It%is%therefore%understandable%that%the%general%assumption%exists%that%nursing% staff%can%draw%blood%because%it%is%in%their%scope%of%practice.%% (q)$Preparation$for$and$assistance$with$operative,$diagnostic$and$therapeutic$acts$for$the$ patient.$$Nursing%Act%50%of%1978%–%Scope%of%practice%for%a%Registered%Nurse.%
(22)

%The%venepuncture%procedure%is%one%skill%that%a%nurse%is%expected%to%perform,%but%teaching% time%spent%on%performing%a%venepuncture%may%vary%from%one%institution%to%another.%%The% phlebotomist%qualification%however%is%an%eighteen:month%certificate%and%on%completion% thereof,%a%person%registers%with%the%HPCSA%(Health%Professions%Council%of%South%Africa).%%This% programme%focuses%primarily%on%the%venepuncture%procedure%and%clear%guidance%given%with% regard%to%the%requirements%of%training%and%competence,%which%will%lead%to%a%person% registering%as%a%phlebotomist.% By%conducting%this%study,%the%researcher%aims%to%investigate%the%value%of%in:service%training% for%nursing%staff%on%the%venepuncture%procedure.%%The%study%can%assist%in%updating%training% programmes,%setting%the%standards%required%for%evaluation%of%skill,%and%updating%standard% operating%procedures.% This%study%will%therefore%be%significant%to:% • The%nurses%working%in%the%laboratory% • The%patients%visiting%the%laboratory% • The%laboratory%(to%improve%their%quality)% • The%supporting%doctors%who%will%receive%reliable%results.% %

1.9

Overview(of(methodology(

Only%a%brief%overview%of%the%research%methods%is%given%in%this%chapter.%A%more%detailed% description%on%the%research%methodology%is%provided%in%chapter%3.%%%%%
(23)

The%research%design%is%one%of%a%pilot%intervention%study%using%a%Pre:test%–%post:test%design.%% (Burns%and%Grove,%2009).% %%%%%%%%%%%%%%%%%%Pre:test%%%%%%%%%%%%%%%%%%%%%%%%%%%%Intervention%%%%%%%%%%%%%%%%%%%%%%%%%%%%Post:test% PreNtest:%%Nursing%staff%were%video%recorded%whilst%performing%a%venepuncture.%%Pre: analytical%technique%errors%made%by%the%nursing%staff%were%identified%by%means%of%reviewing% the%video%material%against%a%criterion%checklist.%%% Intervention:%%Training%was%presented%addressing%the%errors%identified%during%the%pre:test.%% Training%covered%theory;%addressing%the%error%and%the%impact,%that%particular%error%has%on% the%test%outcome,%as%well%as%a%practical%component%to%enhance%the%skill%of%performing%a% venepuncture%to%improve%the%quality%of%the%specimen.%%The%duration%and%the%group%size%of% the%training%depended%on%the%number%of%errors%identified%and%the%intensity%of%the%errors.%%% PostNtest:%%One%month%after%completion%of%the%intervention,%a%video%recording%of%the% venepuncture%procedure%performed%by%the%nursing%staff%was%done.%%This%indicated%to%what% extent%the%errors%identified%during%the%pre:test%were%eradicated.%%The%aim%was%to%achieve% 100%%compliance%in%the%steps%of%a%venepuncture%procedure.% In%the%next%chapter,%the%literature%review,%the%importance%of%training%and%performing%the% venepuncture%procedure%accurately%according%to%set%standards%will%be%discussed.% % !

(24)

Chapter(2:(

Literature(Review(

!

2.1(((Introduction:(

To%have%an%understanding%of%the%importance%of%this%study,%one%has%to%look%at%what%has%been% done%previously,%highlighting%the%important%factors%that%can%make%a%difference.%%It%was% therefore%a%revelation%to%realise%that%in%the%South%African%context%no%studies%have%been%done% on%the%topic%of%the%venepuncture%technique%itself.%%% This%chapter%will%give%more%information%regarding%the%importance%of%laboratory%testing%in% the%medical%fraternity.%%General%mistakes%being%made%in%the%pre:analytical%phase%shed%some% light%on%the%importance%of%quality%assurance%and%how%training%contributes%to%the%success%of% patient%management.% Giuseppe%Lippi%(2009)%states:%%“Medical%errors%can%traditionally%be%clustered%into%four% categories,%which%include%errors%of%diagnosis,%errors%of%treatment,%errors%of%prevention,%and% an%‘other%miscellaneous’%category”.%%Laboratory%tests%consist%of%complex%processes%involving% ordering,%reporting,%interpreting%and%reacting%to%results,%errors%can%be%linked%to%all%4% categories%and%any%mistake%poses%a%serious%health%risk%to%patients.%%(Lippi,%2009).% % The%focus%today%is%on%good%and%affordable%healthcare%for%all.%%If%you%want%to%improve%the% quality%of%laboratory%testing%you%need%to%identify%mistakes%to%minimize%the%effect%through%
(25)

training.%%Improving%the%quality%of%healthcare%by%reducing%errors%in%the%laboratory%may%have% a%favourable%impact%on%patient%safety%and%wellbeing.%%(Sharma,%2009).% Laboratory%tests%are%divided%into%3%phases:%%Pre:analytical,%analytical%and%lastly%post: analytical.%%Nursing%staff%are%mostly%responsible%for%the%extra:analytical%phases%namely%the% pre:analytical%and%post:analytical%phases,%and%errors%occurring%in%the%extra:analytical%phases% are%a%source%of%concern.%%Laboratory%results’%usefulness%is%more%likely%to%be%affected%by% mistakes%made%in%either%the%pre:%or%post:analytical%phase.%%%(Sharma,%2009).%%% Sharma%(2009)%relate%doctors’%complaints%about%incorrect%test%results%to%errors%occurring% during%the%sampling%or%collection%process%of%specimens;%one%of%which%is%incorrect% techniques.%% It%is%therefore%of%the%utmost%importance,%to%ensure%the%quality%of%the%test%result,%that%the% nursing%staff%be%competent%and%confident%when%it%comes%to%the%venepuncture%procedure.%% Wonglumsom%et%al.%(2011)%in%their%study%Evidence:based%learning%as%a%tool%of%competency% improvement%for%the%phlebotomist,%underlined%the%fact%that%specimen%collection%is% dependent%on%correct%processes%to%be%followed%by%competent%staff.%% A%study%done%by%Agarwal,%Chaturvedi,%Chillar,%Goyal,%Pant%and%Tripathi%(2012),%which%looked% at%quality%indicators%influencing%patient%safety%in%the%total%testing%process%in%the%laboratory.% They%concluded%training%is%needed%to%improve%laboratory%staff%members’%skill%by%means%of% practical%sessions,%having%knowledge%of%the%procedure%and%tests%did%not%show%to%have%any% impact%on%the%sample%quality,%evident%in%having%a%reduced%report%of%pre:analytical%errors%but% no%significant%improvement%in%the%number%of%sample%rejections.(

(26)

2.2(((Nurses(vs.(Phlebotomists:(

With%increased%patient%numbers%doctors%realised%they%cannot%keep%up%with%delivering% quality%care%to%patients%they%allow%nursing%staff%to%take%over%responsibilities,%such%as%drawing% bloods%for%laboratory%testing%and%commencing%intravenous%therapy.%%Nurses%are%with% patients%around%the%clock%and%it%just%seemed%sensible%for%nurses%to%perform%these%tasks%on% doctor’s%orders.%%% The%shortages%of%nurses%in%the%hospital%led%to%the%development%of%the%phlebotomist% technician%programme,%launched%in%South%Africa%in%2004.%%The%regulatory%body%and%licensing%%%%%%% authority%is%the%Health%Professions%Council%of%South%Africa%(HPCSA).%%To%register%as%a% phlebotomist%technician%one%has%to%complete%an%18:month%course.%%The%course%covers%an% overview%of%the%basic%anatomy%and%physiology%of%a%human%being,%but%most%time%is%spent%on% the%phlebotomy%procedures.%%A%further%requirement%is%then%to%perform%100%simulated%draws% in%a%skills%laboratory%before%they%have%to%perform%a%further%100%supervised%draws%on%real%%%%%% patients%before%they%are%deemed%competent.% On%the%other%hand%nurses%performing%phlebotomy%procedures%in%the%laboratory%setting%%%%%% receive%in:service%training%or%on%the%job%training.%%New%nursing%staff%was%trained%by%the%older,% more%experienced%nurses%working%in%the%laboratory%that%led%to%the%vast%variations%in% technique.%%Another%factor%affecting%the%differences%in%technique%is%the%lack%of%standardised% training%for%nursing%staff%performing%phlebotomy%procedures.%%(Lima:Oliveira,%Lippi,% Salvagno,%Montagnana,%Picheth%and%Guidi,%2012).%%Unlike%the%phlebotomy%technician% programmes%nursing%staff%do%not%need%a%certificate%for%phlebotomy,%and%therefore%training% programmes%vary%in%requirements%and%set%outcomes%between%different%laboratories.%%
(27)

Another%concern%about%the%training%nurses%receives;%they%are%not%trained%on%tests,%the% requirements%for%these%tests,%and%what%may%influence%the%outcome%of%tests.%%(Lima:Oliveira% et%al,%2012).% %

2.3(((InNservice(training:(

Private%institutions%like%the%laboratories%in%South%Africa%have%come%to%the%realization%that%to% remain%competitive%they%need%to%keep%the%workforce%educated%by%means%of%in:service% training.%%Salas%et%al.%(2012)%has%found%that%organisations%value%the%impact%of%a%well:designed% training%programme%has%on%staff%development,%establishing%a%culture%of%continuous%learning% and%updating%skills.%%Organisations%use%training%and%development%activities%to%have%the%edge% on%their%competitors%as%it%allows%them%to%improve%their%quality%of%service%by%adapting%their% workflow%procedures%in%an%innovative%and%safe%way%and%still%ensuring%they%reach%their%goals.%% (Salas%et%al,%2012).%%Due%to%high%staff%turnover%and%workload%demands,%it%is%imperative%that% companies%must%find%a%way%to%retain%staff%that%is%competent%to%ensure%financial% sustainability.%%The%participants%in%a%study%on%factors%influencing%professional%development% indicate%that%despite%the%efforts%of%companies%to%improve%their%skills,%they%prefer%to%rely%on% their%own%abilities%and%actions%to%improve%their%own%competence.%%This%might%be%due%to%non:% standardization%of%programmes.%%Furthermore%the%participants%identified%experience%and%the% environment%as%the%most%impactful%on%their%development.%%(Khomeiran,%Yekta,%Kiger%and% Ahmadi,%2006).%% %%In:service%training%has%influenced%how%employees%view%the%work%environment%and%has% created%a%higher%work%satisfaction%level.%%Williams%(2010)%stated%that%the%key%to%work%base%
(28)

learning%that%can%change%practice%is%teaching%staff%through%critical%reflection%on%own% behaviour%how%to%learn.%%The%work%place%environment%not%only%allows%the%staff%access%to% develop%skills%with%experienced%people%but%also%enables%them%to%gain%experience%through% practice.%%(Khomeiran%et%al,%2006)%the%work%place%also%provides%the%context%to%develop%self% actualisation%by%creating%an%environment%where%critical%reflection%is%promoted%enabling%staff% to%control%their%own%learning%in%the%workplace.%%% Factors%to%consider%when%designing%an%in:service%training%programme,%which%is%effective%in% staff%development,%should%be:%the%content%to%be%included,%the%place%where%it%would%be% taught%and%how%much%time%the%training%would%take%and%also%what%resources%are%available.%% Learning%should%not%only%consider%what%the%employee%should%learn%but%also%take%into% account%the%needs%of%the%work%place.%Nevertheless,%for%in:service%training%to%be%effective%the% employee%should%be%able,%through%critical%thinking,%to%create%and%apply%knowledge%acquired.%% (Williams,%2010).% Due%to%high%staff%turnover%and%workload%demands,%it%is%imperative%that%companies%must%find% a%way%to%retain%staff%that%is%competent%to%ensure%financial%sustainability.%%In%the%laboratory,% nursing%staff,%considered%to%be%qualified,%draw%blood%samples%from%patients.%In:service% training%is%therefore%the%best%option%to%ensure%competencies%are%upheld.%%Nursing%staff%do% not%need%an%additional%qualification,%however%the%skill%needed%for%the%venepuncture% procedure%is%specialized%and%needs%attention%and%therefore%should%be%included%in%the% training%programme.%% Human%error%will%always%occur%but%needs%to%be%minimized%as%much%as%possible%which%must% be%born%in%mind%when%deciding%on%strategies%to%be%implemented%to%prevent%errors%within%

(29)

the%laboratory.%%Agarwal%et%al.%(2012)%suggested%that%quality%indicators%to%improve%patient% safety%and%care%should%provide%information%about%real%life%scenarios%and%should%comply%with% the%following%suggested%objectives;%all%data%including%near%misses%must%be%looked%at%and%the% complete%process%must%be%evaluated%from%how%the%doctor%ordered%the%test,%the%collection% steps%and%the%testing%phase.%%Having%this%data%will%assist%in%identifying%errors%that%can%be% addressed%through%training%and%implementing%a%quality%assurance%programme.%(Agarwal%et% al,%2012).% In:service%training%is%considered%the%best%platform%to%uphold%competencies%with%the%least% disruption%in%the%workplace.%%According%to%Williams%(2010),%nurses%have%to%take%control%of% their%learning%and%be%empowered%to%make%the%needed%changes%to%their%practice%and%be% supported%when%reflecting%on%their%practice.%%Mentors%play%an%important%role%in%the% education%of%employees%in%the%workplace.%%It%is%imperative%to%structure%and%standardize%the% training%to%minimize%the%variations%in%technique.%%Skilled%facilitation%is%also%needed%to%assist% nursing%staff%with%critical%thinking%that%will%ultimately%affect%change,%but%a%learning%culture% needs%to%be%created%first.%%(Williams,%2010).% On%the%job%or%in:service%training%also%allows%the%employee%to%correct%any%mistakes%without% leaving%the%workplace%to%travel%to%a%different%venue%that%does%not%always%simulate%the%real% life%situation.%%(Presley%and%Liotta,%2006),%in:service%training%has%proven%to%be%a%good% alternative,%to%the%traditional%classroom%based%training,%that%has%proved%to%make%a% difference%in%patient%care.%%(Williams,%2010).%%Williams%(2010)%mentioned%that%learning%in%the% work%place%is%created%from%the%work%itself.%%Through%reflection%the%employee%then%integrates% knowledge%with%experience%in%the%correct%setting.%%Another%skill%the%employees%learn%

(30)

through%in:service%training%is%the%ability%to%question%current%practices%and,%through%debate% with%their%colleagues,%decide%on%best%practices.% Williams%(2010)%concluded%her%study%on%work:based%learning%in%clinical%practice;%to%improve% patient%care%managers%should%consider%implementing%work:base%learning,%as%it%is% motivational%to%staff%that%in%turn%brings%about%better%patient%outcomes.% For%training%to%be%successful%assessment%and%feedback%should%also%be%considered.%%Norcini% and%Burch%(2007)%express%a%concern%that%observation%of%doctors%in%the%workplace%occurs% seldom,%if%ever,%and%that%can%be%said%for%qualified%nurses%in%the%workforce.%%Skill%and% competence%are%rarely%observed%or%assessed%in%the%workplace%even%though%assessment%tools% and%methods%are%readily%available.%%Feedback%on%performance%enhances%not%only%the% learning%and%teaching%but%it%also%assists%with%changing%behaviour%of%employees%(nurses).%% (Williams,%2010).%%Due%to%time%constraints%managers%do%not%provide%timeous%formative% assessments%and%feedback.%%Norcini%and%Burch%(2007)%suggest%that%strategies%should%be% identified%to%improve%the%teaching,%assessment%and%feedback%provided%within%the%workplace% for%it%to%become%a%routine%process.%%After:%training%variations%can%also%occur%and%regular% evaluation%through%observation%of%nurses%and%feedback%given%will%help%with%improving%the% quality%of%service%by%limiting%the%“bad%habits”%to%occur.%%(Ho%et%al,%2002).%% Video%instruction%offers%a%method%of%teaching%nurses%in%the%workplace%as%they%can%view%and% review%the%footage%at%their%own%time%and%pace,%making%notes%in%an%environment%in%which% they%feel%comfortable.%%Video%instruction%can%be%a%great%motivator%and%grab%the%viewer’s% attention%immediately%and%lend%itself%as%a%teaching%tool.%%(Chan,%2010).%%With%the%technology,% i.e.%smart%phones,%tablets%or%laptops;%that%is%readily%available%today%access%to%video%clips%of%

(31)

skills%can%be%viewed%in%any%environment,%at%a%low%cost%being%incurred.%%(Yoo,%Son,%Kim%and% Park,%2009).%%Instruction%through%video%can%be%taken%a%step%further;%using%self:assessment%as% a%teaching%tool.%%Recording%nurses%while%working%will%provide%an%opportunity%for%them%to% review%their%own%practices%and%skills.%Observing%themselves%will%allow%them%to%recognise% their%strengths%and%weaknesses%and%that%will%enhance%the%possibility%for%change%in% behaviour.%%(Yoo%et%al,%2009).%%Dearnley%and%Meddings%(2007)%supported%the%advantages%of% self:assessment%in%their%pilot%study,%finding%that%self:assessment%enhances%learning%and% sense%of%achievement%in%the%student%whom%develops%the%skills%of%critical%awareness%and% reflectivity%enabling%them%to%become%lifelong%learners.% %

2.4(((Venepuncture:((procedural(errors(and(associated(complications:(

According%to%the%World%Health%Organisation,%one%needs%to%follow%certain%steps%to%ensure% safe%practices%in%phlebotomy,%not%only%for%the%patient%and%the%healthcare%worker%but%also%to% ensure%quality%results%to%prevent%repeat%testing%because%of%complications%associated%with% errors%in%sample%collections.%%(WHO,%2008).%%Incorrect%phlebotomy%techniques%such%as%the% venepuncture%often%results%in%complaints%from%doctors%about%wrong%or%unreliable%test% results.%%(Sharma,%2009).% The%best%practice%guidelines%suggest%the%following%steps%for%a%venepuncture%procedure:% • Assembly%of%equipment%(either%needle%and%syringe%or%evacuated%tube%system)% • Performance%of%hand%hygiene%(social%hand%wash)% • Identification%and%preparation%of%the%patient%
(32)

• Selection%of%the%site%–%Ante%Cubital%area%or%dorsum%of%hand.% • Application%of%the%tourniquet.% • Donning%of%non:sterile%gloves.% • Disinfection%of%site%for%30%seconds%and%allow%to%air:dry.% • Anchoring%the%vein%–%pulling%skin%towards%hand%below%puncture%site%and%ask%patient% to%clench%fist.% • Entering%the%skin%with%needle%at%an%angle%below%30°.% • Loosening%of%tourniquet%once%blood%flow%has%been%established.% • Collection%of%samples%in%tubes%–%in%the%correct%order%and%invert%5%times.% • Withdrawal%of%the%needle%and%apply%pressure%to%puncture%site.% • Discarding%needle%safely.% • Labelling%the%specimen%containers.% • Removal%of%gloves%and%decontamination%of%hands.% The%objective%and%expected%outcome%when%performing%a%venepuncture%is%to%obtain%an% uncontaminated%specimen,%which%does%not%allow%erroneous%results,%ensuring%accurate% diagnostic%interpretations%to%minimize%and%prevent%patient%anxiety,%injury,%risk%for%infection% or%misdiagnosis.%%(Lynn,%2011).% Green%(2008)%indicated%that%the%pre:analytical%phase%affects%the%reliability%of%test%results,%not%

(33)

healthcare%resources;%time%to%redo%the%testing,%using%consumables%that%has%a%cost% implication%for%the%laboratory%and%inconvenience%to%the%patient%going%through%the%same% experience%to%mention%a%few.% The%most%common%complications%due%to%procedural%mistakes%associated%with%wrong% phlebotomy%technique%are%haemolysis,%haemoconcentration,%haematoma%and%bruising,% contamination,%sample%rejection%and%lastly%infection.%%As%discussed%in%the%background,% chapter%1.%%% The%complications%due%to%pre:analytical%errors%linked%to%technique%variations%could%be% prevented%and%managed.%%The%laboratory%is%involved%in%decisions%relating%to%medical% diagnoses%and%treatments,%(Agarwal%et%al,%2012)%placing%the%laboratory%in%the%midst%finding% solutions%to%improve%patient%safety%through%improving%the%total%testing%process.%%Error% prevention%would%need%control%measures%that%would%require%compliance%from%all%staff%in%the% laboratory,%controlled%by%an%accreditation%system.%(Sharma,%2009).%%% %

2.5(((Quality(assurance:((Current(status(in(South(Africa:(

A%quality%assurance%programme%to%overcome%human%errors,%increase%patient%safety%in%the% laboratory,%and%eliminate%possible%errors%is%needed.%%Hawkins%(2011)%stated%in%his%review%of% managing%the%extra:analytical%phase:%%“Accreditation%agencies%are%increasingly%requiring% laboratories%to%go%beyond%analytical%quality%and%take%responsibility%for%the%pre:%and%post: analytical%(or%extra:analytical)%phases%where%most%errors%arise.”%%Phlebotomy%procedures%are% poorly%investigated%even%though%it%is%a%major%source%for%errors,%it%also%lack%quality%control% procedures.%%(Lima:Oliveira%et%al,%2012).%
(34)

Hawkins%(2011)%states%that%lack%of%control%measures%will%lead%to%errors%that%could%be% prevented%if%the%correct%processes,%procedures%and%guidelines%were%in%place.%%%% Although%the%pathology%sector%has%been%in%the%forefront%for%quality%improvement%and% implementing%accreditation%standards%in%South%Africa,%the%focus%remains%on%the%analytical% phase.%%The%South%African%National%Accreditation%System%(SANAS)%is%the%body%that%visits%and% inspects%the%pathology%laboratories%in%South%African%according%to%ISO%standard%17025% (www.sanas.co.za).%%They%measure%each%step%in%the%laboratory%against%a%pre:determined% checklist%and%make%recommendations%accordingly.%%However,%the%only%criterion%on%these% checklists%for%the%extra:analytical%phases%are%measured%against%the%laboratory’s%standard% operating%procedures,%these%procedures%set%by%the%nursing%staff%working%in%the%laboratory%as% phlebotomists%contain%no%reference%to%best%practices.%%%%% Green%(2008)%concluded%his%study%on%specimen%quality%by%saying%that%improvement%could%be% achieved%through%education.%%The%solution%should%include%quality%audits%and%the% development%of%assessment%criteria%of%specimen%collection%practices.%%It%has%to%be%an% ongoing%process,%looking%at%identifying%problem%areas%and%finding%workable%solutions%to% minimize%the%recurrence%of%inefficient%laboratory%practices.%%The%aim%is%to%sustain%specimen% quality%and%improve%safety%measures.% So%the%question%arises%:%do%the%current%practices%with%regards%to%training%for%nurses%in%the% laboratory%improve%their%phlebotomy%skill%and%are%the%standard%operating%procedures% guiding%them%according%to%best%practices%being%implemented?% In%chapter%3,%the%research%process%followed%is%explained.%%How%the%process,%enabled%the%

(35)

Chapter(3:(

Research(Methodology(

!

3.1(((Introduction:(

Research%methodology%is%the%systematic%approach%taken%by%the%researcher%to%find% solutions%for%a%particular%research%question.%%It%encompasses%the%various%steps%and% logical%reasoning%taken%by%the%researcher%to%study%the%problem.% The%research%methodology%guides%the%researcher%when%deciding%what%are%the%most% appropriate%methods%and%techniques%to%use%for%data%collection,%population%selection%as% well%as%data%analysis.%%In%this%chapter%the%research%process%is%outlined%and%each%step%of% the%process%is%explained%from%the%research%setting,%population%and%sampling,%data% collection%and%how%the%data%was%analysed.% %

3.2(((Research(methodology:(

A%quantitative,%experimental,%pilot%intervention%study%was%used%for%the%purpose%of%this% study.%%This%methodology%was%thought%to%provide%the%most%suitable%guidance%for%the% research%questions.%%It%determined%the%methods%of%data%collection%as%well%as%what% techniques%and%principles%to%apply%when%analysing%the%data.% % Quantitative(research:%%“is%a%formal,%objective,%systematic%process%in%which%numerical%
(36)

describe%variables,%examine%relationships%among%variables,%and%determine%cause:and: effect%interactions%between%variables.”%%(Burns%and%Grove,%2009).% % Experimental(research:%%The%idea%of%experimental%research%is%to%compare%two%things% with%one%another.%There%are%three%main%categories%of%experimental%designs%identified% namely:%%pre:experimental,%quasi:experimental%and%true%experimental.%%Differences% between%the%experimental%designs%are%the%degree%of%control%of%the%variables%and%if%a% comparison%group%was%used%or%not.%Experimental%research%provides%a%platform%to% conduct%intervention%studies%as%it%allows%the%researcher%to%determine%what%is%known% about%the%study,%subjects%or%intervention%and%to%determine%if%there%is%any%difference% between%before%and%after.%%(de%Vos%et%al,%2013).%%%%%%% % Pilot(study:%%A%pilot%study%can%be%seen%as%a%small:scale%version%of%the%complete%project,% before%a%researcher%attempts%to%conduct%the%research%mainly%to%establish%and%rectify%any% discrepancies%and%also%to%determine%the%feasibility%of%the%study.%%(de%Vos%et%al,%2013).%% The%reasons%the%researcher%used%a%pilot%study%to%conduct%this%research%are%as%follows:%% • Determining%the%feasibility%in%terms%of%cost%involvement%and%practicality%of%the% implementation%of%the%intervention.% • Cost%implications%in%developing%the%intervention,%in:service%training%programme,% for%professional%nurses%working%in%the%laboratory.%

(37)

• Design%a%protocol%for%implementation%of%the%intervention%to%assure%quality%within% the%laboratory%setup.%%% • Finally,%because%of%the%small%number%of%available%participants,%a%pilot%study%is%done% to%gather%information%to%answer%the%research%questions.%%(Burns%and%Grove,%2009).% A%pilot%study%only%provides%limited%information,%however%it%still%allows%for%identification% of%deficiencies%that%can%be%addressed.%%(Burns%and%Grove,%2009).% %% Intervention(research:%%Interventions%are%treatments%or%programmes%that%are% implemented%that%will%result%in%change%of%behaviour%to%improve%quality%of%care.%% Intervention%research%aims%to%provide%a%platform%for%the%generation%of%knowledge,% nurses’%use%as%evidence%for%best%practices.%%Burns%and%Grove%(2009).% %

3.3(((Research(design:(

The%research%design%chosen%for%this%study%is%a%pre:experimental%design%namely%a%one: group%pre:test/post:test%design.%%De%Vos%et%al%(2013)%states:%%“These%designs%have%been% developed%to%determine%the%presence%of%cause:and:effect%relationships%between% different%variables.%%In%technical%terms,%it%means%that%we%want%to%measure%whether%a% specific%intervention%(independent%variable)%has%any%effect%on%the%unit%of%analysis% (dependent%variable).”%The%one:group%pre:test%–%post:test%design%was%chosen%for%this% study%as%it%enabled%the%researcher%to%test%if%in:service%training,%the%intervention,%has%an% effect%on%the%current%phlebotomy%practices%of%registered%nurses%(the%participants),%even%
(38)

if%it%creates%awareness%that%training%is%needed%to%update%their%skills,%a%positive%outcome%is% reached.% %

3.4(((Overview(of(research(plan:(

The%study%was%conducted%in%three%phases.%%The%first%was%to%validate%the%criterion%based% checklist%(Annexure%A.1)%used%during%the%pre:test%and%post:test.%%It%was%accomplished%by% running%a%trial%run%of%the%pre:%and%post:test%using%phlebotomy%technicians%(excluded% from%the%study)%as%participants%allowing%the%assessors%to%familiarise%themselves%with%the% tool.%%The%validation%process%is%explained%later%in%this%chapter%3.7.1.% Data%collection%took%place%during%the%second%phase%and%in%the%last%phase%additional% information%and%statistics%were%obtained%from%the%various%laboratories%to%compare%the% outcome%of%the%intervention%with%what%is%happening%in%practice;%for%example%the% researcher%obtained%information%from%the%laboratory%concerning%sample%rejection% numbers%and%compare%the%information%with%the%results%of%the%study.%%Due%to%the%number% of%participants,%the%researcher%was%able%to%obtain%valuable%data%from%the%participants%as% feedback%on%the%intervention%and%their%experience%on%the%process,%which%was%looked%at% in%the%last%phase.%%% % % % %
(39)

% A%summary%of%the%methodology%can%be%seen%in%figure%3.1%below.%% % Figure%3.1%%Summary%of%Research%Plan%

Phase 1

%

Checklist

Validation

%

In-vivo

session with

phlebotomist

technicians

%

%

Content and

face validity

%

Phase 2

%

Step 1

Pre-test

%

• Consent forms% • Video recordings% • Demographic questionnaire completion% %

Step 2 - Analyse

pre-test data

%

• Assessors identify errors% • Moderation

%

%

Step 3 -

Intervention

%

• Design training% • Facilitate programme% %

Step 4

Post-test

%

• Video recording% %

Step 5 - Analyse

post-test data

%

Phase 3

%

Statistics on

sample rejection

%

%

Demographic

questionnaire

%

%

Feedback from

participants

%

Objective!1! 11!1! Objective% 2% % Objective!3!
(40)

3.5(((Research(setting:(

The%study%was%conducted%in%a%natural%setting.%%The%reason%for%conducting%the%study%in%a% natural%setting%was%to%observe%nurses’%behaviour%in%their%work%environment.%%It%is%very% difficult%to%replicate%the%workplace%in%a%simulated%situation%as%stressors%that%occur%on%a% daily%basis%cannot%be%predicted%and%replicated.%%The%workplace%environment%is%also% familiar%to%the%nurses%and%they%should%be%comfortable%in%the%environment,%reducing%the% added%stressors%of%being%assessed%that%would%have%occurred%if%it%had%been%done%in%a% training%room.%%%Data%was%collected%at%outpatient%departments%(depots)%of%a%private% laboratory,%which%are%based%at%private%hospitals%in%the%Gauteng%South%Region.%%The% laboratory%has%a%STAT%lab%on%site%and%is%the%preferred%service%provider%at%these%hospitals,% with%a%high%demand%for%pathology%testing,%requiring%more%phlebotomy%staff.% %

3.6(((Population(and(sample:(

The%population%was%made%up%of%nurses%working%for%a%private%laboratory%in%the%Gauteng% South%region.%%The%nurses%were%based%at%laboratories%at%five%private%hospitals.%%The% original%population%amounts%to%53(N).%Due%to%policy%changes%that%were%made%after% commencement%of%this%study%that,%upon%resignation%of%nurses%from%their%posts,% phlebotomy%technicians%would%be%employed%in%their%positions,%two%hospitals%became% unsuitable%for%the%purpose%of%this%study%as%they%experienced%a%high%turnover%of%staff% between%the%period%of%proposal%submission%and%data%collection.%%The%final%population% size%was%N=35.%
(41)

Census%sampling%was%used%for%the%purpose%of%this%study.%%Due%to%the%limited%numbers%of% registered%nurses%working%at%the%laboratory,%the%whole%population%had%to%be%included.%% The%final%sample%size%was%20%(n).%%The%sample%is%57%%of%the%population%that%participated% in%the%study.%The%nurses%who%were%not%included%in%the%final%sample%were%either% unavailable%or%refused%participation%and%therefore%did%not%sign%consent.%%%%%% Patient(selection:%%The%presence%of%the%STAT%laboratories%at%these%hospitals%makes%it% convenient%for%doctors%to%refer%their%patients%for%blood%tests%on%an%outpatient%basis%to% the%laboratory.%%The%outpatient%numbers%are%large%and%enabled%random%selection%of% patients%on%whom%the%nursing%staff%can%perform%the%venepuncture%procedure%for%this% study.%%Every%third%adult%patient%who%visited%the%Depot%of%the%STAT%laboratory%and%who% agreed%to%participate%was%included.%%The%reason%for%random%selection%of%patients%was%to% exclude%biases%and%favouritism%from%the%nursing%staff,%as%well%as%it%prevented%the%nursing% staff%member%pre:empting%which%patient%they%were%about%to%bleed.%%% Exclusion(criteria:%%Phlebotomy%technicians%were%not%participating%in%the%study%as%they% completed%an%18:month%phlebotomy:training%programme%and%are%registered%as% phlebotomist%technicians%with%the%HPCSA.%%% Inclusion(criteria:%%All%nursing%staff,%which%is%permanently%employed%by%the%private% laboratory,%based%at%the%three%private%hospitals%in%the%Gauteng%South%Region.% %

3.7(((Research(method:(

This%study%consisted%of%a%pilot%study,%conducted%to%establish%the%feasibility%of%the%study% and%of%the%intervention.%%The%aim%was%to%describe%the%phlebotomy%process%and%to%gather%
(42)

evidence%of%procedural%variations%that%may%affect%the%outcome%of%the%test;%develop%a% training%programme%to%prevent%procedural%variations%and%test%the%effectiveness%thereof.%%%

3.7.1(((Phase(1:((Validating(instrument:(

The%first%step%in%this%study%was%to%check%the%feasibility%of%using%the%existing%procedure% evaluation%instrument%(Annexure%A.2)%as%a%research%tool.%%%This%instrument%is%currently% used%by%the%laboratory%as%an%assessment%tool%for%competence%of%the%phlebotomist% technician:learning%programme.%%Instrument%validity%ensures%that%the%instrument% measures%the%concept%(steps%in%the%venepuncture%procedure)%and%that%it%is%measured% accurately.%(de%Vos%et%al,%%2013).%%% Content$validity%ensures%that%all%the%components%to%test%a%variable%are%represented%in% the%tool.%%(Brink,%van%der%Walt%and%van%Rensburg,%2012).%%%The%first%step%taken%by%the% researcher%to%ensure%content%validity%was%to%look%at%WHO’s%procedural% recommendations%on%the%procedural%steps%for%a%venepuncture%and%doing%a%literature% review%on%factors%that%influenced%the%various%steps%of%the%procedure.%The%checklist%used% to%observe%the%pre%and%post:tests%is%derived%from%a%checklist%currently%used%in%the% phlebotomy%technician’s%programme%(Annexure%A.2).%%As%this%study%only%focused%on%the% venepuncture%technique%of%the%nursing%staff%member,%non:applicable%criteria%such%as% patient%identification,%test%confirmation%and%hand%decontamination%were%omitted.% Face$validity%is%concerned%with%the%representativeness%of%the%content%of%an%instrument% and%if%it%measures%all%aspects%of%the%concept.%(de%Vos%et%al,%2013).%%This%was%done%by% running%an$in=vivo%session%with%phlebotomy%technicians,%whom%have%been%excluded%from% the%study%as%the%participants,%the%assessors%used%the%tool%to%identify%any%problems%with%
(43)

the%content,%steps%in%the%procedure,%and%they%could%familiarize%themselves%with%the%tool.% (Annexure%A.3).%%The%assessors,%experts%in%the%phlebotomy%field,%comprised%of%a%nursing% service%manager%in%phlebotomy%and%a%training%sister%at%the%laboratory,%made%judgements% on%the%inclusions%and%exclusions%of%the%criteria%used%in%the%checklist.%%The%following% changes%were%made%to%the%checklist,%because%of%their%feedback,%and%then%used%as%a% criterion%checklist%for%the%video%recordings:% • Each%criterion%was%broken%down%into%smaller%steps.% • Comments%from%the%assessor%added%as%field%notes.% Changes%to%the%checklist%is%shown%in%table%3.1% Table%3.1%%Changes%to%Checklist% Step(in(Procedure( Criteria( Positioning(Patient( 1.%%Fully%extends%the%patient’s%arm% Applying(the(tourniquet( 2. Apply%10%–%15%cm%above%puncture%site% 3. Ensure%tourniquet%is%not%too%tight% 4. Loosen%the%tourniquet%within%60%sec% Selecting(a(suitable(vein( 5. Palpate%the%vein%to%determine%direction%and%patency% 6. Ask%patient%to%hold%fist%–%no%pumping%of%hand% Disinfecting(the(site( 7. Clean%the%site%% 8. Allow%the%adequate%time%for%alcohol%to%air%dry% Anchoring(the(vein( 9. Do%not%re:palpate%the%site% 10.Anchors%the%vein%by%pulling%the%skin%downwards%towards% the%hand%

(44)

Needle(insertion:( 11.Angle%of%needle%insertion%is%less%than%20°%% 12.Did%not%bend%the%needle% Filling(of(collection(tubes:( 13.Loosen%tourniquet%once%blood%flow%is%established% 14.Wait%for%vacuum%to%be%exhausted%before%removing%the% tube% 15.Mix%the%tube%by%inverting%it%% 16.Fill%tubes%in%the%correct%order% Removal(of(the(needle:( 17.Release%the%tourniquet% 18.Remove%needle%and%apply%pressure%to%site% % Reliability$of%an%instrument%as%defined%by%de%Vos%et%al,%(2013):%when%an%instrument% provides%the%same%result%on%repeated%measurements.%%Steps%to%improve%reliability%include% standardizing%instructions,%elimination%of%unclear%instructions%and%maintaining%consistent% scoring%procedures.%During%the%in=vivo%sessions,%the%instrument%was%tested%for%reliability.%% It%provided%an%opportunity%to%standardize%the%instructions%and%to%see%if%the%instrument% was%consistent.%%As%per%the%feedback%from%the%assessors%the%tool%proved%to%be%easy%to%use% and%scoring%was%consistent%not%only%from%one%observation%to%the%next%but%also%the%scores% of%the%evaluators%were%similar%which%assured%inter:rater%reliability.% %

3.7.2(((Phase(2:((Data(collection:(

The%research%design%of%a%pre:test%–%post:test%allowed%the%researcher%to%collect%valuable% information%regarding%the%venepuncture%technique%applied%by%nursing%staff%members.%% Observations%were%done%by%means%of%video%recordings%of%the%procedure,%which%were%
(45)

then%evaluated,%using%a%criterion%based%evaluation%sheet.%%Video%recordings%of%human% behaviour%have%certain%benefits%over%in:person%observation,%which%directed%the%decision% to%use%recordings%for%the%purpose%of%this%study.%%Recordings%are%less%threatening%to%the% participants%as%it%feels%less%like%an%assessment%and%would%minimize%change%of%daily% routine%and%behaviour.%%The%generation%of%additional%information%that%an%in:person% observer%might%have%missed%is%an%added%benefit,%it%allows%the%reviewer%the%opportunity% to%stop%and%replay%and%make%notes%without%interrupting%the%process%enabling%improved% judgements.%%(Paterson,%Bottorff%and%Hewat,%2003).% %

3.7.2.1(((PreNtest:(

The%pre:test%was%done%by%means%of%video%recordings,%of%the%nursing%staff%in%the%depot% whilst%performing%a%venepuncture%on%patients.%%Two%independent%evaluators%evaluated% the%recording%against%the%criterion%based%evaluation%sheet.%%The%aim%of%the%pre:test%was% to%identify%procedural%errors%made%by%the%nursing%staff%that%can%have%an%influence%on%the% test%outcome,%which%was%included%in%the%intervention.%%Once%all%the%procedural%errors% were%identified,%the%intervention%was%designed%and%implemented.%%The%number%of% procedural%errors%or%the%frequency%of%occurrence,%even%though%documented,%was%not%a% factor%in%deciding%on%inclusion%in%the%intervention.%%All%procedural%errors%identified%were% included%in%the%intervention.% % %
(46)

3.7.2.2(((Intervention:(

The%intervention%was%in%the%form%of%a%training%programme,%given%in%the%workplace,% addressing%all%procedural%errors%identified%during%the%pre:test.%%Salas%et%al%(2012)%stated% that%training%is%not%just%a%classroom%activity%that%enables%learning;%it%actually%is%needed%to% improve%performance%in%the%workplace.%%%%As%explained%in%the%background%of%chapter%1,% nursing%staff%were%exposed%to%an%induction%programme%where%simulators,%limbs,%were% used%to%demonstrate%the%procedure%and%an%opportunity%to%practice%the%skill%was%given.%% Due%to%time%constraints,%staff%shortages%and%access%to%these%simulators%another% approach%was%necessary%to%allow%staff%to%perfect%their%skill%in%the%workplace.%%% The%training%programme%focused%on%the%following%aspects:% • The%correct%steps%in%the%venepuncture%procedure.% • Implications%of%variations%in%the%procedure.% • Complications%of%variations%in%the%procedure.% • Influence%on%test%outcome%quality%of%variations%in%the%procedure.% The%training%methodology%was%a%group%(peer)%learning%approach.%%The%nursing%staff% watched%a%video%explaining%the%steps%of%a%venepuncture%procedure.%%They%had%to% evaluate%the%procedure%and%then%give%feedback%on%the%implications.%%A%group%discussion% was%held%to%derive%best%practices%based%on%the%evidence.%Colleagues%captured%the%video% recordings%of%the%pre:test%so%they%had%the%opportunity%to%view%their%peers%in%action%and% it%was%also%covered%in%the%discussion%session.%%The%participants%had%the%opportunity%to% perform%the%procedure%and%be%evaluated%by%peers%in%the%workplace.%%The%advantage%of%
(47)

this%was%that%of%immediate%feedback%on%performance%from%their%colleagues.%Feedback% from%the%participants%on%their%experience%gave%valuable%insight%on%the%way%forward%for% on%the%job%training.% %

3.7.2.3(((PostNtest:(

The%same%format%was%followed%with%the%post:test%as%with%the%pre:test.%%Video%recordings% of%the%nursing%staff%were%done%in%the%depots,%whilst%performing%a%venepuncture% procedure.%%Again,%the%recordings%were%evaluated%by%two%independent%evaluators,% against%the%same%criterion%based%evaluation%sheet,%used%during%the%pre:test.%%Procedural% mistakes%were%identified%and%the%frequency%noted.( %

3.7.3(((Phase(3:((Additional(information:(

Each%participant%(nursing%staff%member)%was%asked%to%complete%a%demographic% questionnaire.%(Annexure%B)%This%enabled%the%researcher%to%have%a%better%understanding% of%the%characteristics%of%the%sample%of%nursing%staff%in%the%laboratory.%%Questions%asked%in% the%questionnaire%covered%areas%of%age,%training%and%years%of%experience%in%the%field.%% The%reason%for%these%questions%was%to%relate%procedural%errors%to%these%demographics% that%might%have,%to%a%lesser%extent,%impact%on%the%intervention.((Statistical%information% was%obtained%from%the%laboratory%about%the%sample%rejections%during%the%pre:test%and% post:test,%to%see%if%there%was%an%improvement%in%the%number%of%sample%rejections.%% Currently%the%laboratory’s%quality%assurance%system%does%not%link%sample%rejection% directly%to%the%venepuncture%technique%of%the%nursing%staff.%%(
(48)

3.8(((Data(analysis:(

Data%analysis%for%quantitative%studies,%such%as%this%study,%falls%into%four%main%categories:%% descriptive,%association,%causation%and%inference.%%(de%Vos%et%al,%2013).%%Descriptive%data% analysis%was%used%because%of%the%small%sample.%%In%de%Vos%et%al%(2013)%descriptive% statistics%are%described%as:%“methods%used%to%report%the%distributions%of%a%sample%or% population%across%a%wide%range%of%variables.%%The%aim%of%these%methods%is%to%produce%a% scope%of%the%characteristics%of%such%distributions%through%frequencies,%measures%of% central%tendency%and%measures%of%dispersion.”%%Because%only%a%small%group%participated,% descriptive%statistics%were%used%to%describe%the%basic%features%of%the%study.%%It%provided% meaningful%data%relevant%to%an%education%programme,%and%helped%with%understanding% the%mean%and%standard%deviation.% Two%independent%evaluators%used%a%criterion%based%observational%evaluation%form%for% both%pre:%and%post:tests,%to%evaluate%the%video%recordings.%%The%total%scores%indicated%the% compliance%level%to%the%procedure%standards.%%Additional%control%assured%by%obtaining% feedback%from%the%performing%laboratory%on%the%sample%quality%of%all%specimens% collected%in%the%study.%%Statistics%from%the%laboratory%enabled%the%researcher%to% determine%if%there%was%a%decline%in%the%number%of%rejected%samples.%%The%researcher% fulfilled%the%role%of%moderator,%and%reviewed%the%data%collected%to%ensure%all%problems% were%identified%and%addressed%in%the%training%programme%and%that%the%post:test%results% gave%a%true%reflection%of%the%effectiveness%of%such%a%training%programme.%%% % %
(49)

3.9(((Validity(and(reliability(of(study:(

Internal%and%external%validity%of%experimental%designs%have%a%number%of%threats%that%have% to%be%minimized%by%the%researcher%for%the%study%to%be%successful.%%Although%this%is%a%pilot% study%efforts%were%made%to%limit%threats%to%the%validity%and%reliability%of%the%study.%The% threats%that%had%the%potential%to%influence%the%outcome%of%this%study,%identified%by%the% researcher,%were%the%demand%factor%(occurs%when%participants%are%aware%of%what%the% research%is%all%about%and%change%their%behaviour%to%what%they%conceive%is%expected%of% them)%and%what%is%called%the%Hawthorne%effect%(participants%react%differently%to%real%life% because%of%their%participation%in%a%study)%(de%Vos%et%al,%2013).%%To%prevent%the%occurrence% of%the%demand%factor%and%the%Hawthorne%effect%the%researcher%asked%the%nursing%staff%to% video%record%one%another%(peer%recording)%to%minimize%changes%in%behaviour%that%may% occur%when%an%outsider%observes%the%proceedings%(limit%the%demand%factor)%and%it%would% feel%less%like%an%assessment%that%would%also%result%in%changed%behaviour%(limit%the% Hawthorne%effect).( Standards%for%performing%a%venepuncture%are%universal%and%set%up%according%to%the%WHO% guidelines%for%phlebotomy%and%the%unit%standard%published%on%the%SAQA%website.%%The% criterion:based%tool%used%for%this%study%is%based%on%these%standards.% Inter%–rater%reliability%was%established%by%having%two%independent%evaluators%observe% and%evaluate%the%video:recordings%of%the%nurses%performing%the%phlebotomy%procedure% in%both%the%pre:and%post:training%conditions,%using%the%same%criterion%based%evaluation% tool.%%%
(50)

Evaluators,%two%nursing%managers%working%in%departments%in%another%area%and%not%in% the%Gauteng%South%region%not%included%in%the%study%were%used%to%review%the%recordings% to%exclude%supervisor%/%supervisee%complications%and%biases,%as%they%do%not%know%the% nursing%staff%participating%in%the%study%and%don’t%oversee%the%departments%included%in% the%study.%%% %

3.10(((Ethical(considerations:(

Anonymity:%%No%patient%or%nursing%staff%member%was%identifiable%on%the%recordings% as%the%video%recordings%only%displayed%the%Ante%Cubital%fossa%area%of%the%patient%and% the%hands%of%the%nurse.%%No%identifiable%content%was%captured%as%the%study%excluded% the%patient%identification%and%labelling%of%the%samples%procedures%so%there%was%no% risk%of%compromising%anonymity.% • Confidentiality:%%The%video%recordings%cannot%be%traced%back%to%a%specific%individual% or%laboratory%site.%%Nursing%staff%work%shifts%so%recordings%of%all%nursing%staff%could% not%be%recorded%in%one%day.%%The%sites%were%visited%on%more%than%one%occasion.%%The% researcher%had%a%list%of%all%staff%names%in%alphabetical%order%not%by%location%and% ticked%off%once%they%had%been%recorded.%%The%recordings%therefore%cannot%be%linked% to%a%specific%individual.%%The%researcher%aimed%to%identify%procedural%errors%and%not% who%made%the%errors,%therefore%no%recording%could%be%linked%to%a%specific%individual.%% The%video%recorder%gave%a%code%for%each%new%recording%to%separate%between%the% participants.%%The%pre:test%and%post:test%recordings%were%captured%on%separate% memory%cards.%
(51)

Consent:%was%obtained%from%all%nursing%staff%participating%in%the%study%and%the% patients%from%whom%they%drew%blood.%%Participation%was%voluntary%and%no%staff% member%or%patient%was%forced%to%take%part.%%They%could%also%withdraw%at%any%stage% without%any%prejudice.%%(Annexure%C.1).%%Patients%who%agreed%to%have%their%blood% drawn%also%received%an%information%letter%and%consent%was%obtained%from%them.%% (Annexure%C.2)% • Data(collected:%%The%video%recordings%were%done%to%identify%mistakes%made%not%who% made%the%mistakes%and%to%evaluate%the%effectiveness%of%training.%%Information% gathered%cannot%be%traced%back%to%a%specific%person.%%The%raw%data%was%only% accessible%to%the%researcher%and%supervisor.% • Evaluation:%%%Independent%evaluators%were%used.%%No%participant%reported%to%these% evaluators%in%the%laboratory.%%The%outcomes%therefore%could%not%influence%their%work% relations%within%the%laboratory.%%% • Permission:%to%conduct%the%study%was%obtained%from%the%management%of%the%private% laboratory%(Annexure%D.1)%and%the%University%of%the%Witwatersrand%Ethics% committee.%%(Annexure%D.2).%%

Researcher:%%No%participant%or%evaluator%reported%to%the%researcher%or%vice$versa.%% The%researcher%has%no%influence%on%the%career%pathway%of%any%participant%or%

evaluator.%%On%commencement%of%research%the%researcher%was%in%the%employment%of% the%private%laboratory%but%had%resigned%once%data%collection%commenced.%

(52)

Possible(harm(to(patients:%%In%the%event%the%evaluator%observed%procedures%that% might%be%harmful%to%the%patients%it%was%reported%to%the%nursing%managers%of%all%the% participating%departments,%to%address%the%issue.%%The%laboratory%has%quality% measures%in%place%preventing%employees%to%try%more%than%once%to%obtain%a%blood% sample.%%On%the%recordings%was%only%one%nurse%that%had%the%tourniquet%on%so%tight% that%it%left%a%red%mark%on%the%patient’s%arm,%though%it%is%not%life%threatening%it%was%still% reported%to%all%the%managers.% The%research%process%has%been%described%in%this%chapter,%looking%at%the%design%of%the% research%and%method%of%data%collection%that%enabled%the%researcher%to%obtain%information% to%answer%the%research%questions.%%In%chapter%4,%the%findings%of%the%study%are%explained.% % % % % % % % % %

(53)

Chapter(4:(

Findings(

!

4.1(((Introduction:(

In%this%chapter%the%findings%from%the%descriptive%analysis%will%be%explained%as%well%as%the% results%obtained%from%the%questionnaires%given%to%the%participants%in%the%study.%%%% %

4.2(((PreNtest(results:(

The%pre:test%consisted%of%video%recordings%that%were%measured%against%a%criterion%based% checklist.%%The%checklist%had%18%criteria,%which%the%nursing%staff%had%to%perform%during%a% venepuncture%procedure.%%(Annexure%A.1).% The%performance%of%the%participants%during%the%pre:test%averaged%at%61.9%,%calculated%as% follows:% % Number%of%correct%steps%in%the%procedure%performed%by%participants% % %%%%%%%%%%%%%%%Total%number%of%steps%(18%steps/procedure%x%20%participants)% %% % % 20%x%223%÷%360%=%61.9% % In%order%to%interpret%the%findings%of%the%pre:test,%findings%have%been%divided%into%three% groups%namely%steps%that%more%than%15%participants%performed,%steps%of%the%procedure%that%
(54)

were%performed%by%10%–%15%participants%and%lastly%steps%of%the%procedure%that%were% performed%by%less%than%10%of%the%participants.%% % Steps%that%more%than%15%participants%performed:% % Figure%4.1%Top%Performers% % Figure%4.1%illustrates%steps%of%the%venepuncture%procedure%15%:%20%of%the%participants% performed%correctly.%%% • Step$1:%%Fully%extend%the%patient’s%arm;%nineteen%participants%positioned%the%patient% correctly.% % 19 17 20 17 18 19 15 16 17 18 19 20 21 1. Extend arm

7. Clean site 11. Needle angle 16. Correct order 17. Release tourniquet 18. Remove tourniquet Top Performers

(55)

Step$7:%%Clean%the%site;%seventeen%participants%disinfected%the%puncture%area.%

Step$11:%%Angle%of%needle%insertion%less%than%20°, all%participants%entered%the%skin%

with%the%needle%at%an%angle%less%than%20°.% • Step$16:%%Filled%the%containers%(tubes)%in%the%correct%order;%seventeen%participants% comply%with%this%step.% • Step$17:%%Loosen%the%tourniquet%once%blood%flow%has%been%established%was% performed%by%eighteen%participants% • Step$18:%%Apply%direct%pressure%on%the%puncture%site%after%the%removal%of%the%needle;% nineteen%participants%applied%direct%pressure%to%site%after%the%needle%was%removed.% % 10%–%15%of%participants%performed%the%following%steps%of%the%procedure%correctly:% % 13 13 10 14 13 11 0 5 10 15 2. Tourniquet application 4. Tourniquet on 1 minute 5. Palpate vein 12. Don’t bend needle 13. Loosen tourniquet 15. Invert tubes Middle Performers

(56)

The%following%steps,%as%illustrated%in%figure%4.2,%was%performed%correctly%by%the%10%–%15% participants:% • Step$2:%%Apply%tourniquet%10%–%15%cm%above%puncture%site:%%Thirteen%participants% applied%the%tourniquet%correctly.% • Step$4:%%Loosen%the%tourniquet%within%one%minute.%%Thirteen%participants%loosened% the%tourniquet%within%60%seconds.% • Step$5:%%Palpate%vein%for%direction%and%patency.%%Ten%participants%palpated%the%vein%to% feel%for%direction%and%patency.% • Step$12:%%Do%not%bend%the%needle:%%Fourteen%participants%did%not%bend%the%needle% before%needle%entry%into%the%skin.% • Step$13:%%Loosen%the%tourniquet%once%blood%flow%was%established:%Thirteen% participants%loosen%the%tourniquet%once%blood%flow%was%established.% • Step$15:%%Inverted%the%tubes%after%filled%with%blood:%%Eleven%participants%inverted%the% tubes%to%mix%blood%with%additives.% % Less%than%10%participants%per

References

Related documents

Prior to the visual search displays, observers were presented with a colour cue that indicated either the target colour (positive cue), the colour of the to-be-ignored

There are also several academic health science institutions, including Baylor College of Medicine, The University of Texas Health Science Center at Houston, the University of

A ppendices R ecommenda tions Findings Ta ble of Contents Highlights Expanding the performance evaluation methodology for BSN staff… Enhancing the customer experience

As you know, everything in the universe is composed of energy and energy never dies, it only transmutes (transforms) from one form to another. When we talk about any form of

The expansion of aquaculture and the recent development of more intensive land-based marine farms require commercially-valuable halophytic plants for the treatment

In this context, a major aspect of Katib C ¸ elebi’s work is his interest in the world outside the Islamic oecoumene (on his biography see Collective work, 1957; for a selection of

A third gesture that was observed frequently is characterized by a flat hand pose (10),the palm facing the subject(10) and the hand approaching subject’s upper body (10).When it

In addition to considering whether Customs’ Four-year Excellence Horizon continues to be appropriate and if Customs is on track to deliver its strategy and fulfil its